While many aspects of operation and administration at hospitals and other health care facilities have been computerized over the past years, one of the most important aspects, the generating of patient care or health plans, the updating of these plans and the generation of progress notes by health care professionals, such as doctors, nurses, therapists, and the like, is still performed largely by hand. As a result, while a care plan of some type is normally generated shortly after a patient is admitted to a particular service, for example an intensive care unit (ICU), cardiac surgery unit, or the like, this care plan is seldom referred to thereafter and is seldom if ever updated to reflect actual progress by the patient.
Another problem is that, since the care plan is not referred to in most cases when the professional is preparing progress notes on the patient, there is no check to assure that the original care plan has in fact been followed, or that proposed resolution dates in the original care plan have been met or updated. When changes in the original care plan are made as a result of changes in patient status, such changes are frequently not entered with the original care plan, and no good archival record is generally maintained of car plan changes. The professional notes for a particular patient frequently do not have available an updated version of the patient's care plan. Further, even though a form may be available for progress notes, the form does not take into account the unique problems of the individual patient, and does not give the professional a checklist of items to be investigated for such problems or suggested interventions or resolution dates for the particular patient problem. When changes are made or expected outcomes are not achieved, the reasons for such occurrences are seldom provided, making any further review far more difficult. Again, a good archival record of what has been done for the particular patient is not readily available.
Because of the absence of good archival records, and the absence of reasons for changes or deviations, tracking a problem for quality control, legal or other reasons is difficult, and it is difficult to research the relative effectiveness of various interventions or to perform other research from the records.
Even with computer based patient health plans and/or progress note systems, many of the problems indicated above still exist. Such systems also, in many instances, lack flexibility so as to be configurable by the user as to indexes and problems; problems, outcomes, interventions and the like for a given problem; default frequencies and schedules for interventions and due dates for outcomes, etc. In addition, they frequently do not give the user the ability to add special instructions or to add items as required. Further, it is generally not possible to obtain either an updated care plan or a historical care plan on request.
A need therefore exists for an improved hospital patient documentation method and apparatus which facilitates the generation of the initial care/health plan by providing the health care professional or other user with preselected options at each stage in the procedure which a user can quickly and easily select by use of a cursor or other suitable means. The user should preferably be able to see the plan as it develops in addition to viewing the available options at each stage in the development. It is also preferable that each menu item placed in the system be coded to facilitate performing computer searches on such items, thereby facilitating the use of the system for audit, quality control, legal, research, or other purposes.
It is further desirable that progress notes also be produced from a menu driven system, with the menu items being keyed to the particular problems for the particular patient, and any changes made in the care/health plan as a result of changes in patient status as documents in the progress notes be utilized to automatically update the care/health plan. However all versions of the care plan, including the initial care plan, and all updates should be stored in the system, preferably in coded form, to again facilitate various search activities.